Sunday, November 29, 2009

Medical Information and the Outbreak Narrative

In last week's section, we discussed different forms of marking and the stigmas that accompany them in Wald's outbreak narrative. This investigation led me to consider yet another form of marking: marks created by medical record (mis)management and, more specifically, the new mark created by the online transmission of medical information. Communications between doctor and patient are generally considered to confidential, but in the digital age - an age in which information becomes less and less stable - new possibilities for an accessible and rapidly communicable mark are made possible. Take for example this Brown University Health Services agreement, composed in 2003:

"E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients. E-mail is not a “secure” means of communication.

Recipients can forward e-mail messages to other recipients without the original sender’s permission or knowledge.

Users can easily misaddress an e-mail message.

E-mail may be altered and is easier to falsify than handwritten or signed documents.

Backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy.

E-mail containing information pertaining to a patient’s diagnosis and/or treatment constitutes a part of the patient’s medical record.

All e-mail may be discoverable in litigation regardless of whether it is in a patient’s medical record. [...]

I understand the assumptions stated above and that e-mail is not a secure means of communication. I am aware that the provider may decline to communicate via e-mail based upon the nature of the medical information. I give permission for Health Services to electronically communicate with me."

The proposal is unsettling. The language used to describe electronic records mirrors Wald's language of the contagious outbreak and underscores the possibility of an informational mark with a viral nature that is easily altered and transmitted. Such language makes the patient aware that medical information circulated online could be kept alive as easily as the contagion it might address. Like a virus, the nature of email permits it to make copies of itself, and become "molecular shark, a motive without a mind' (43). The way in which the medical system communicates becomes more and more like a metaphor for the harm it seeks to curtail. Information about carriers, contagions, and the victims they touch, becomes contagious itself. Wald reminds readers that the "word contagion literally means 'to touch together', and one of its earliest uses in the fourteenth century referred to the circulation of ideas and attitudes. It frequently connoted danger or corruption. Revolutionary ideas were contagious, as were heretical beliefs and practices. […] The medical use of the term was no less metaphorical than its ideational counterpart" (12). Both metaphorical uses incite fear.

At the same time, Wald's own description of a viral web continually echoes the structure of internet communication. She explains how the "explosion of a disease outbreak into an epidemic or pandemic marks, in this formulation, the tragic consequences of human behavior amplified by the web" (23). She also says, "A Hot Virus in the rainforest lives within a twenty-four hour plane flight from every city on earth. […] All of the earth's cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day" (35). Whether one is shooting and email or a virus, the vocabulary is consistent.

In the same way that "communicable disease marks the potential destruction of the community and the consequence of its survival," the internet both creates new hope for communities of victims, as well as new possibilities for indelible marks and de-stabilized systems of confidential doctor-patient communications. Wald's condition for the containment of contagions, the "endless vigilance on the part of people we never see" (22), is the same unreasonable and perhaps unattainable condition for the curtailment of viral digital information and and the unprecedented marks that it makes possible.

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